ProBTP and Counter Fraud
Transcription
ProBTP and Counter Fraud
IBM Counter fraud Management client story ProBTP and Counter Fraud How to deal with a delicate corporate&society subject © 2015 © 2015 IBM Corporation IBM Corporation Before starting … © 2015 IBM Corporation A little bit of background on : Healthcare payers landscape in France 11.6% Is the Part of the GDP for the Social Security expenditure -24 From 1300 to 250 For Supplementary Social # : 2005 vs 2015 Security Companies -9 Compulsory Social Security Supplementary Social Security • Concentration • Stronger competition •ButClearer competition … © 2015 IBM Corporation A little bit of background on : The ProBTP context – Why to Industrialize Counter Fraud now (2013) Activity Fraud & Abuse Impact for ProBTP Fraud Compulsory Social Security plan • Switch : in 2013 • Better Understanding of financial impact Risk • Regulation evolution • Difficulty to recover the money Supplementary Social Security © 2015 IBM Corporation Objective : Understand the value ProtBTP conviction cycle Start : 2013 June POC : 2013 October– 3 weeks Decision : 2013 December Signature : Postponed (2013) Before : 1% detected & 15% Positive In october : 10% detected & 70% positive X X XX Why not signed if decided ? $ X X Pipe Analysis Data / Optic 2 years history CFM Analytics © 2015 IBM Corporation Proof of value : 7% • Great result • Contract But in november, Predictive on history approach • Switch from a ProBTP to based a Market Beneficiary information …. Predictive – Anomaly detection • ProBTP with IBM partnership Heathcare profesionnals…. • Decision : Build a SaaS Business for the Rules market • Claims Signature in 2014 MarchIdentity & networks Proof of concept : 10% Supplementary Social Security X Zoom on the solution to Counter Fraud & Abuse in Healthcare Payment process Reminder : project has started on 2014 april 2018 • Roadmap : where we are – where we go • • • • • Oct 14 : Dental & Optical & PostPayment May 15 : Pre Payment Oct 15 : Audio & Medical Transport June 16 : Medecine & Pharma Oct 16 : Daily allowance 2017 2016 2015 2014 • Technical platform • Based on IBM Counter Fraud Management • Business Pack : Solon (Healthcare Fraud) • Detection • Fraud Score • Alerte & Next best action © 2015 IBM Corporation SOLON: An externalized service platform (SaaS) 4 Mutuals (+) Healthcare Operator Payment Claims 3.1M Benefiaries 7M Benefiaries 50k+ Professionals 90% Professionals Platform Solon Immediate 6 monthPayback Payback 250% 300% ROIROI (average) Insurance against fraud • Inbound : 1) Claims, practitioner’s dataset, contract rights. 2) Client feedback on claims and fraud detection (confirmed fraud / false positive) • Outbound : results from the detection engine, configurations sets, action models • Transaction access to the platform : reports, performance measurement © 2015 IBM Corporation Solon Combines 5 Analytical Engines Profiling 1 2 Configurations, Alerts, Reports Experience-based predictive modeling (supervised learning mode) 3 Business rules and indicators (existing experience & continuous improvement) Visual analysis of relationships between insured/beneficiaries, health providers, … Action Atypical traits detection (anomaly detection) 5 4 © 2015 IBM Corporation A view on the Solon capabilities • Reporting / dashboard • Understanding the detection within the application screens • Investigating a case © 2015 IBM Corporation Solon : A Solution Against Frauds, Errors and Abuses • Immediately operational • Safety and confidentiality of your data. • CFM & Expertise on Healthcare at IBM • Community system to share the new fraud behavior indicators & coordinate dissuasive actions • An immediate return on investment • A counter fraud observatory © 2015 IBM Corporation My « take away » proposal with Solon platform – ProBTP experience • 1 to 10 France vs England Olympics medals average difference A factor 10 efficiency for fraud detection •7 Number of wonders of the world % of TRUE fraud vs total claim reimbursement amount • 300 Watson should have said : what is the Zack Snyder film? % ROI with IBM Counter Fraud Management • 3 to 7 millions Evolution of my sales quota between H1 and H2 Evolution of beneficiaries # on the Solon SaaS platform © 2015 IBM Corporation Our commitment to a Safer Planet © 2015 IBM Corporation © 2015 IBM Corporation PANEL Questions & Answer © 2015 IBM Corporation